Publicly Funded HIV Counseling and Testing --
United States, 1991

Human immunodeficiency virus (HIV) counseling and testing (CT)
services provided by health departments are a major component of
the national HIV-prevention program. The purpose of HIV CT is to 1)
reinforce perception of risk by those who are unaware or
uninformed, 2) help uninfected persons initiate and sustain
behavior changes that reduce their risk for becoming infected, and
3) identify HIV-infected persons who can be referred for early
medical care and counseled to practice safer behaviors. The use of
publicly funded HIV CT has steadily increased; in 1991, nearly
2,091,000 HIV-antibody tests were performed, compared with
approximately 79,000 tests in 1985. CT services are provided by
health departments in 65 HIV-prevention project areas including the
50 states, the District of Columbia, six cities, and eight
territories. * Each calendar quarter, the programs report to CDC
data regarding the number of pretest counseling sessions,
HIV-antibody tests, positive tests, and posttest counseling
sessions. Information is also provided on self-reported risk
category, age group, sex, and race/ethnicity. This report
summarizes data reported for 1991. **

The data presented here are collected by number of
HIV-antibody tests, rather than number of persons tested. Because
testing of some clients is repeated, the exact number of persons
tested is not known.
Serologic Testing Results by Type of HIV CT Site

Of 1,997,415 HIV tests for which self-reported risk
information was available, the highest percentage of positive test
results was among homosexual/bisexual male injecting-drug users
(IDUs) (17.4%); for homosexual/bisexual males who were not IDUs,
seroprevalence was 11.8%, and for heterosexual IDUs, 8.3% (Table
2). These three categories accounted for 15.9% of tests and 58.4%
of positive results from persons who reported risk category.

"Heterosexual males and females with reported risk" (including
heterosexuals whose sex partners are at risk for or are infected
with HIV and heterosexuals with multiple sex partners) accounted
for 489,014 (24.5%) tests and 9142 (16.2%) positive results.
Persons categorized in "other/no acknowledged risk" accounted for
1,161,120 (58.1%) tests. This category is composed predominantly of
self-reported heterosexual males and females who indicated no
history of risk behavior or no partner(s) at risk for or infected
with HIV, or persons for whom risk information is not specified.
***
Combined, these persons (heterosexual males and females with
reported risk and those with other/no acknowledged risk) had a
seropositivity rate of 1.4% but accounted for 40.5% of reported
positive results.
Demographic Categories

Of 1,993,353 tests for persons for whom demographic
information was given, race/ethnicity was specified for 1,956,872
(98.2%). Of HIV tests performed, whites, blacks, and Hispanics
accounted for 51.2%, 33.4%, and 11.7%, respectively, compared with
their representation in the U.S. population of 75.7%, 11.8%, and
9.0%, respectively (1). The racial/ethnic distribution of those
tested was similar to that of new reports of persons with AIDS in
1991, of whom 48.8% were white, 32.0% were black, and 18.0% were
Hispanic (Table 3) (2). Whites, blacks, and Hispanics accounted for
34.4%, 43.3%, and 19.5%, respectively, of all positive tests (Table
3). Seropositivity was highest among Hispanics (4.6%), followed by
blacks (3.6%).

Males accounted for 1,006,773 (50.5%) of the 1,993,353 tests
and 42,527 (76.6%) of the 55,520 positive results. Seropositivity
in males and females was 4.2% and 1.3%, respectively. Of persons
for whom age was known, persons aged 20-29 years accounted for
42.7% of tests and 34.4% of positive results, and persons aged
30-39 years accounted for 27.3% of tests and 41.8% of positive
results. Seropositivity rates for persons aged 20-29 and 30-39
years were 2.2% and 4.3%, respectively. For adolescents aged 13-19
years, 261,942 tests were performed; of these, 1242 (0.5%) were
positive.
Posttest Counseling

Client record data, representing a 60% subset of the aggregate
CT data and providing greater detail about persons receiving CT,
indicated that at least 74.0% of persons with HIV-antibody-positive
test results and 62.8% of those with negative test results
completed posttest counseling (3). Overall, at least 63.1% of
persons in the client record database received posttest counseling;
however, the proportion of persons receiving posttest counseling
was higher for freestanding test sites (81.2%) than for STD clinics
(40.6%).

Reported by: HIV-prevention programs of state and local health
departments. Program Development and Technical Support Section,
Program Operations Br, Div of Sexually Transmitted Diseases and HIV
Prevention, and Office of the Director, National Center for
Prevention Svcs, CDC.

Editorial Note

Editorial Note: Knowledge of HIV-infection status and
client-centered counseling can increase self-perception of risk and
assist persons in initiating changes in behavior that will reduce
their risk for infecting others or for becoming infected (4,5).
Successful HIV-prevention counseling involves four essential
components: 1) personalized risk assessment to facilitate a
realistic self-perception of risk; 2) identification and discussion
of barriers to behavior change and reinforcement of positive
behavior change already initiated by the client; 3) negotiation
between the client and counselor of a realistic and incremental
risk reduction plan; and 4) establishment of a specific plan to
receive test results and posttest counseling (6). CT services
include partner notification and referral for early intervention
and other prevention services. Early intervention, including
medical evaluation, antiretroviral therapy, and pharmacologic
prophylaxis, can enhance and prolong the years of productive life
for HIV-positive persons. A substantial proportion of persons
infected with HIV have been diagnosed and have received services at
publicly funded CT programs (7).

Because data presented in this report are for persons tested
at public clinics, the findings are not representative of all
persons tested in the United States. Most of these data were
collected in service-delivery settings where risk behaviors are
self-reported and not validated through epidemiologic or research
investigations. An unknown number of persons are tested for HIV
antibody in hospitals, outpatient medical facilities, physicians'
offices, blood-donation centers, military facilities, and other
settings (8). In addition, an unknown number of the tests presented
in this report may represent retests; the client record data system
began collecting data on repeat tests in January 1992.

One possible explanation for the difference in return rates
for freestanding sites and STD clinics relates to the reason for
client visit. In particular, persons attend freestanding sites
specifically to obtain an HIV-antibody test and, therefore, are
motivated to return for results; in comparison, persons attend STD
clinics primarily for clinical care of an STD and are offered HIV
CT as a supplemental component of that clinical care (9).
Therefore, programmatic efforts have been directed toward
increasing the proportion of persons who receive posttest
counseling, including field follow-up of persons who are
HIV-positive or are HIV-negative but at high risk for HIV infection
and who do not return for their results.

To ensure that persons with undetected HIV infection receive
appropriate CT, public health priorities should focus on increasing
testing of persons engaging in risk behaviors and increasing the
number who receive the full range of recommended CT, referral, and
partner-notification services. HIV-antibody-positive persons who
are not tested anonymously and who do not return for posttest
counseling should receive timely and effective follow-up to ensure
provision of test results, posttest counseling, and appropriate
referrals.

HIV CT services should continue to expand within settings such
as tuberculosis, STD, and drug abuse-treatment clinics. In
addition, recent reports indicate HIV-infected persons may be
identified through hospital-based HIV CT programs (10). Public
health programs should attempt to maximize the proportion of
persons at risk who 1) are offered and receive pretest counseling,
including risk assessment; 2) accept and receive HIV-antibody
testing; 3) return for HIV-antibody test results; 4) are offered
and receive posttest counseling; 5) if infected, participate in
partner notification; and 6) if infected, are referred to and
receive further medical and prevention services.

References

Bureau of the Census. Data tape: state and metropolitan
area -- regions, divisions, and states. Washington, DC: US
Department
of Commerce, Bureau of the Census, 1990.

Cities are Chicago, Houston, Los Angeles, New York City,
Philadelphia, and San Francisco. Territories are American Samoa,
Federated States of Micronesia, Guam, the Marshall Islands, the
Northern Mariana Islands, Palau, Puerto Rico, and the Virgin
Islands.
** Because several areas do not report all variables on each person
tested (i.e., risk factor(s), sex, age, and race/ethnicity), the
total number of tests presented in each table may differ.
*** In the client record data, representing 60% of aggregate CT
data, persons for whom risk information is not specified are 74.9%
of the "other/no acknowledged risk" category.

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